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DPD COURSE > Interactive gastrointestinal cases - amir sam > Flashcards

Interactive gastrointestinal cases - amir sam Flashcards

1
Q

Inspection of hands (abcdefgh)

A

a. Asterixis (liver flap)
b. Bruising
c. Clubbing
d. Dupuytren’s contracture
e. Erythema
f. Fetor (smell)
g. Gynaecomastia
h. Hair loss
i. Icteris
j. Jaundice
k. Leuconychia - low albumin

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2
Q

inspection of arms

A

av fistula

current or prevous renal replacement therapy

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3
Q

inspection of head and neck

A
  • anaemia
  • jaundice
  • skin: jaundice, excoriation marks (itching) or spider naevi (press let go, fills from centre)
    oral: Pigmentation or Gum hypertrophy (? on ciclosporine after renal transplant)
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4
Q

inspection of chest

A

a. Gynaecomastic, hair loss, excoriation, spider naevi

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5
Q

inspection of abdomen

A

a. Abdominal distension

b. Caput medusae (portal hypertenion): recanalisation of umbilical vein
i. Distended superficial abdominal veins
ii. Direction of flow in the veins below the umbilicus is towards the legs

c. Scars

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6
Q

causes of hepatomegaly

A
  1. cancer
  2. cirrhosis
  3. cardiac - congestive cardiac failure, Constrictive pericarditis : high JVP, ascites
  4. infiltration - FLASH
    a) Fat
    b) Haemochromatosis
    c) Amyloidosis
    d) Sarcoidosis
    e) Lymphoproliferative diseases
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7
Q

causes of liver diseases

A
  • Alcohol
  • Autoimmune
  • Drugs
  • Viral
  • Biliary disease
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8
Q

causes of splenomegaly

A

H: portal hypertension
H: haematological
Infection
Inflammation

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9
Q

classifying ddx of gi

A

abdo pain, abdo distension, change of bowel habit, gi bleed, jaundice, ascites

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10
Q

case: epigastric pain that radiates to the pain. haemodynamically compromised (low bp)

A

ruptured aortic aneurysm

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11
Q

abdominal pain nature types n causes

A

Constant: inflammation e.g. cholecystitis

Colicky: bowel obstruction, stone

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12
Q

medical causes of acute generalised abdo pain

A

DKA, addisonians crisis, hypercalcaemia, porphyria, lead poisoning

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13
Q

epigastric pain ddx

A

stomach:

  1. peptic ulcer (?NSAID)
  2. GORD (better w antacids)
  3. gastritis (retrosternal, ETOH)
  4. malignancy (weight loss)
pancreas:
acute pancreatitis (?Gallstones, high amylase)

above (heart): MI

below (aorta): ruptured aaa

right (liver/gallb): 1. choleycstitis
2. hep

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14
Q

acute pancreatitis presentation

A

pain and high amylase/lipase

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15
Q

chronic pancreatitis presentation

A
  1. pain, wt loss, 2. loss of exocrine function -steatorrhoea
  2. Loss of endocrine function - diabetes
  3. Normal amylase
  4. Faceal elastase
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16
Q

RUQ pain ddx

A

GB: cholecystitis, cholangitis, gallstones

liver: hepatitis, abscess
above: basal pneumonia
below: appendicitis (long retrocaecal appendix inflamed)
left: peptic ulcer, pancreatitis, Meckels diverticulum?
right: kidney - pyelonephritis

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17
Q

RIF pain ddx

A

GI: appendicits, mesenteric adenitis (children) - look at lymph nodes on US, colitis IBD, malignancy

Gynae: ovarian cyst rupture/twist/bleed, ruptured ectopic pregnancy

kidney stones, diverticulitis (caecal)

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18
Q

suprapubic pain ddx

A

cystitis and urinary retention

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19
Q

LIF pain ddx

A

diverticultis, colitis (IBD), malignancy

ovarian cyst rupture, twist bleed. ectopic pregnancy

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20
Q

diffuse abdominal pain ddx

A
  1. obstruction
  2. infection - peritonitis, gastroenteritis
  3. inflammation - ibd
  4. ischaemia - mesenteric ischaemia
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21
Q

leaking aaa repair blood tests:

A

high lactate - hypoperfusion
low bicarbonate - acidotic
high amylase - goes up in any cause of acute abdomen

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22
Q

what is spontaneous bacterial peritonitis

A

more than 250 neutrophil cells/mm^3

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23
Q

abdominal distention - fluid clues

A

ascities: shifting dullness, signs of liver disease

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24
Q

abdominal distention - flatus clues

A

Obstruction:

  • Nausea, vomiting
  • Not opened bowel - ask about last time
  • High pitched tinkling BS
  • ?Previous surgery (adhesions)
  • ?Tender irreducible femoral hernia in groin
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25
Q

how is ascites classified

A

transudate <30 or exudate >30

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26
Q

causes of transudate ascites

A
  1. Cirrhosis
  2. Cardiac failure
  3. Nephrotic syndrome
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27
Q

causes of exudate ascites

A
  1. Malignancy is more common (abdo, pelvic, peritoneal mesothelioma)
  2. Infection e.g. TB, pyogenic
  3. Budd Chiari syndrome: hepatic vein thrombosis, Portal vein thrombosis
28
Q

cause of pale stool

A

stone blockage stops conjugated bilirubin from entering duodenum so there is low/no stercobilinogen

29
Q

causes of prehepatic jaundice

A

haemolysis (spleen), defective conjugation - low glucuronidation (Gilberts)

30
Q

causes of hepatic jaundice

A

hepatitis - alcohol, autoimmune, drug, viruses

31
Q

cause of post hepatic jaundice

A

CBD obstruction (gallstone CBD, cancer in head of pancreas, stricture)

32
Q

cause of dark urine

A

Leakage of conjugated bilirubin into blood from damaged hepatocytes

33
Q

hb down and bilirubin up

A

sign of haemolysis

34
Q

what symptoms are in both hepatic and post hepatic jaundice

A

dark urine and pale stool

35
Q

painless jaundice diagnosis

A

pancreatic cancer

36
Q

what will liver function tests show in obstruction (post hepatic jaundice)

A

high alp

37
Q

what is a tumour marker for pancreatic cancer

A

Ca19-9

38
Q

when is AST raised

A

damaged hepatocytes

39
Q

bloody diarrhoea ddx

A

infective colitis, inflammatory colitis,

ischamic colitis, diverticultis, malignancy

40
Q

causes of infective colitis

A 
CHESS
1. Campylobacter
2. Haemorrhagic E.coli
3. Entamoeba histolytica
4. Salmonella
5. Shigella
Send cultures for microscopy, culture, sensitivity, C.diff toxin
41
Q

who is inflammatory colitis more common in

A

young people

42
Q

what are some extra gi manifestations

A
  • Ulcers
  • Clubbing
  • Scleritis - red eyes
  • Arthritis
  • Erythema nodosum - tender lesions on legs
43
Q

who is ischaemic colitis more common in and how to investigatw

A

elderly, imaging, lactate and ck bloods

44
Q

how to investigate inflammatory colitis

A

colonoscopy, mucus

45
Q

abdominal x ray

A

1) Thumb prints - thickened haustral folds, bowel wall thickening
2) Featureless colon - IBD
3) Toxic megacolon - > 6cm
a) Fluids, hydrocortisone, abdominal x-ray to detect toxic megacolon, call the surgeon’s due to perf risk
4) Diarrhoea
- Overflow spurious diarrhea due to faecal loading

46
Q

management of acute gi bleed

A
  1. ABC
  2. iv access
  3. fluids
  4. G&S , X-match blood
  5. OGD when stable
47
Q

how to manage varciceal bleed

A

1) Abx - Reduces mortality

2) Terlipressin injection-Splanchnic constrictor, vasopressin analogue

48
Q

investigations for acute abdomen

A

FBC (anaemia), U+E (renal), LFTs, CRP, Clotting, G+S, x-match

  • Erect CXR (perforation)
  • CT
49
Q

what LFTs go up in hepatic jaundice

A

AST and ALT

50
Q

management of acute abdomen

A
  • NBM (nil by mouth)
  • Fluids
  • Analgesics
  • Anti-emetics
  • Abx: cefuroxime, metronidazole
  • Monitor vitals and UO
51
Q

investigations for jaundice

A
  1. Bloods: FBC, LFT, CRP

2. Abdo US - After a fast - gallstones better visualised in a distended, bile filled GB

52
Q

investigations for dysphagia and weight loss

A

OGD and biopsy

53
Q

investigations for PR bleed and weight loss

A

colonoscopy

54
Q

management plan for ascites patient

A

Tap + send, Drain, Monitor

  1. Diuretics: spironolactone (blocks secondary hyperaldosteronism) ± frusemide only if peripheral oedema
  2. Dietary sodium restriction
  3. Fluid restriction in patients with hyponatraemia
  4. Monitor weight daily
  5. Therapeutic paracentesis: with IV human albumin
55
Q

where do samples go to

A
  1. Chemistry: BM, protein
  2. Microscopy, culture, sensitivities
  3. Cytology: malignant cells
56
Q

management of encephalopathy

A

1) Lactulose 10ml TDS: stimulate bowel movement - osmotic
a) Reduces transit time
b) Less time for bacteria to work and make toxic products

2) ± Phosphate enemas
3) Avoid sedation
4) Treat infections: sepsis makes encephalopathy worse
5) Exclude a GI bleed

57
Q

if serum albumin - ascites albumin is >11g/L what is the cause

A

cirrhosis, cardiac failure because the albumin in the ascites is low

58
Q

if serum albumin - ascites albumin is >11g/L what is the cause

A

TB, cancer, nephrotic syndrome

high albumin in ascites due to infection.

59
Q

post op care complications

A

wound infection, anastomotic leak and pelvic abscess - post appendectomy

60
Q

features of a wound infection

A

erythematous, discharge

61
Q

features of anastomotic leak

A

diffuse abdo pain, guarding, rigidity, hypotensive, tachycardic

62
Q

features of pelvic abscess

A

pain, fever, sweats, mucus diarrhoea

63
Q

presentation and treatment of perianal abscess

A

tender, red swelling.

incision and drainage

64
Q

presentation and treatment of anal fissure

A

-Rectal pain on defecation and Stool coated with blood

Advice RE diet (fluids, fibre), GTN: relaxation effect

65
Q

presentaton of ibs

A

recurrent abdo pain, bloating , improves w defecation, change in freq/form of stool, no pr bleed, anaemia, wt loss or nocturnal symptoms, exclude coeliac

66
Q

treatment of ibs

A

diet n lifestle modification. symptomatic rx: abdo pain - antispasmodics, laxatives and anti-diarrhoeals

67
Q

ddx of ibs

A

malignancy and coeliac

DPD COURSE (5 decks)

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